1
|
Davidson KR, Ha DM, Schwarz MI, Chan ED. Bronchoalveolar lavage as a diagnostic procedure: a review of known cellular and molecular findings in various lung diseases. J Thorac Dis 2020; 12:4991-5019. [PMID: 33145073 PMCID: PMC7578496 DOI: 10.21037/jtd-20-651] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Bronchoalveolar lavage (BAL) is a commonly used procedure in the evaluation of lung disease as it allows for sampling of the lower respiratory tract. In many circumstances, BAL differential cell counts have been reported to be typical of specific lung disorders. In addition, more specific diagnostic tests including molecular assays such as polymerase chain reaction (PCR) or enzyme-linked immunosorbent assay, special cytopathologic stains, or particular microscopic findings have been described as part of BAL fluid analysis. This review focuses on common cellular and molecular findings of BAL in a wide range of lung diseases. Since the performance of the first lung irrigation in 1927, BAL has become a common and important diagnostic tool. While some pulmonary disorders have a highly characteristic signature of BAL findings, BAL results alone often lack specificity and require interpretation along with other clinical and radiographic details. Development of new diagnostic assays is certain to reinforce the utility of BAL in the future. Our review of the BAL literature is intended to serve as a resource to assist clinicians in the care of patients with lung disorders.
Collapse
Affiliation(s)
- Kevin R Davidson
- Division of Pulmonary Sciences & Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Duc M Ha
- Division of Pulmonary Sciences & Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.,Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado, USA.,Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado, USA
| | - Marvin I Schwarz
- Division of Pulmonary Sciences & Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Edward D Chan
- Division of Pulmonary Sciences & Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.,Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado, USA.,National Jewish Health, Denver, Colorado, USA
| |
Collapse
|
2
|
Benign Solitary Pulmonary Necrotic Nodules: How Effectively Does Pathological Examination Explain the Cause? Can Respir J 2020; 2020:7850750. [PMID: 32695245 PMCID: PMC7361885 DOI: 10.1155/2020/7850750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 06/07/2020] [Accepted: 06/15/2020] [Indexed: 11/18/2022] Open
Abstract
Aims We investigated the histopathological features of solitary pulmonary necrotic nodules (NNs) of undetermined cause. We combined our findings with those obtained using other methods to determine how well the etiological factors were explained. Methods We screened patients who underwent surgery to treat solitary pulmonary granulomatous and nongranulomatous NNs of undetermined cause. The NN sizes and features of both the NNs and adjacent parenchyma were evaluated. Histochemical analyses included Ehrlich-Ziehl-Neelsen (EZN), Grocott, and Gram staining. Polymerase chain reaction (PCR) was used to detect tuberculous and nontuberculous mycobacteria, panfungal DNA, Nocardia, Francisella tularensis types A and B, and actinomycetes. Results The NNs were granulomatous in 78.9% and nongranulomatous in 21% of the 114 patients included. EZN staining or PCR was positive for Mycobacterium in 53.5% of all NNs: 62.2% of granulomatous and 20.8% of nongranulomatous NNs. We found a weak but significant correlation between granulomatous NNs and Bacillus positivity and a significant correlation between granulomas surrounding the NNs and the presence of multiple necroses. The NN etiology was determined via histopathological, histochemical, and PCR analyses in 57% of patients but remained undetermined in 42.9%. Conclusion The causes of both granulomatous and nongranulomatous NNs can be determined by pathological examination. Granulomatous necrosis and granulomas in the adjacent parenchyma are important for differential diagnosis. When both features are present, they strongly support a diagnosis of tuberculosis, even in the absence of bacilli.
Collapse
|
3
|
Yamada M, Nakashima K, Ito H, Aoshima M. Severe acute respiratory failure due to Sai-rei-to-induced lung injury successfully treated by multi-modal therapy including immunosuppressive therapy, plasma exchange, and intravenous immunoglobulin: A case report. Respir Med Case Rep 2019; 28:100955. [PMID: 31709142 PMCID: PMC6831833 DOI: 10.1016/j.rmcr.2019.100955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Revised: 10/07/2019] [Accepted: 10/15/2019] [Indexed: 11/19/2022] Open
Abstract
Corticosteroid therapy may not be enough to control pneumonitis in some cases of severe drug-induced lung injury (DLI); however, an advanced treatment strategy for such cases is lacking. Here, we report the case of an 88-year-old man who presented with severe DLI, caused by Sai-rei-to. The patient visited our hospital complaining of progressive dyspnea. High-resolution computed tomography of the chest demonstrated bilateral patchy ground-glass opacities and infiltrative shadows. Nasal high-flow oxygen therapy was initiated because of severe hypoxemia. Bronchoalveolar lavage on admission revealed diffuse alveolar hemorrhage. Further, as the patient had started taking Sai-rei-to a month earlier, DLI caused by Sai-rei-to was the most likely diagnosis. Therefore, Sai-rei-to was stopped and steroid pulse therapy was initiated. However, he still required high-flow oxygen therapy. We considered an alternative diagnosis of Goodpasture syndrome or anti-neutrophil cytoplasmic antibody (ANCA) related vasculitis. We initiated the administration of cyclosporin A and therapeutic plasma exchange (TPE), but his respiratory condition did not improve satisfactorily. Therefore, we also initiated intravenous immunoglobulin (IVIG) therapy for the treatment of potential vasculitis. Subsequently, his respiratory status began to improve. Further, tests for anti-glomerular basement membrane antibody, myeloperoxidase-ANCA, and proteinase 3-ANCA revealed negative results. Drug-induced lymphocyte stimulation test performed six months after withdrawing methylprednisolone was positive for Sai-rei-to. Thus, the final diagnosis was DLI due to Sai-rei-to. Our findings demonstrate that in cases of severe acute respiratory failure due to DLI, the multi-modal therapy with plasma exchange and IVIG in addition to conventional treatment with prednisolone and immunosuppressant may be beneficial.
Collapse
Affiliation(s)
- Midori Yamada
- Department of General Medicine, Awa Regional Medical Center, 1155, Yamamoto, Tateyama-shi, Chiba, 294-0014, Japan
- Department of Pulmonology, Kameda Medical Center, 929 Higashi-cho, Kamogawa-shi, Chiba, 296-8602, Japan
- Department of Family Medicine, Kyoto Min-iren Asukai Hospital, 89 Tanaka Asukai-cho, Sakyo-ku, Kyoto-shi, Kyoto, 606-8226, Japan
- Corresponding author. Department of General Medicine, Awa Regional Medical Center, 1155, Yamamoto, Tateyama-shi, Chiba, 294-0014, Japan.
| | - Kei Nakashima
- Department of Pulmonology, Kameda Medical Center, 929 Higashi-cho, Kamogawa-shi, Chiba, 296-8602, Japan
| | - Hiroyuki Ito
- Department of Pulmonology, Kameda Medical Center, 929 Higashi-cho, Kamogawa-shi, Chiba, 296-8602, Japan
| | - Masahiro Aoshima
- Department of Pulmonology, Kameda Medical Center, 929 Higashi-cho, Kamogawa-shi, Chiba, 296-8602, Japan
| |
Collapse
|
4
|
Bunker DR, Meinhof KT, Hiensch RJ, Ghaw O, Becker CD. A 26-year-old woman with respiratory decompensation in the immediate postpartum period at Mount Sinai Medical Center in New York City. Thorax 2015; 70:1095-7. [PMID: 26245803 DOI: 10.1136/thoraxjnl-2015-207250] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Accepted: 07/15/2015] [Indexed: 11/04/2022]
Affiliation(s)
- Daniel R Bunker
- Division of Rheumatology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Klaus T Meinhof
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Robert J Hiensch
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Olivia Ghaw
- Division of Rheumatology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Christian D Becker
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| |
Collapse
|
5
|
Wang H, Sun L, Tan W. Clinical features of children with pulmonary microscopic polyangiitis: report of 9 cases. PLoS One 2015; 10:e0124352. [PMID: 25923706 PMCID: PMC4414499 DOI: 10.1371/journal.pone.0124352] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Accepted: 03/02/2015] [Indexed: 12/04/2022] Open
Abstract
Kidneys and lungs are the most common organs involved in microscopic polyangiitis (MPA). A retrospective analysis of pediatric MPA patients with pulmonary lesions over the past 10 years was performed to investigate clinical features of MPA in children with pulmonary lesions. There were 9 patients enrolled in our study, including 2 boys and 7 girls, with a median age of 6.6 years at the time of disease onset and a median disease course of 2 months. All of the patients exhibited tachypnea, and 7 exhibited cough and hemoptysis. The most common presentation on pulmonary imaging was ground glass or patchy shadows, which were observed in 6 cases. Seven patients manifested with hematuria and proteinuria, with renal histopathology of fibrinoid necrosis/exudation of the glomerular capillaries. All of the patients presented with normocytic normochromic anemia. Of the 9 patients, 7 were positive for perinuclear antineutrophil cytoplasmic antibody (p-ANCA) and/or myeloperoxidase (MPO), and 2 were positive for p-ANCA/MPO and cytoplasmic ANCA/proteinase 3. Eight patients had normal complement 3 (C3) levels, and one had an elevated C3 level. Five of the 9 patients were positive for antinuclear antibody ANA, and 4 were positive for double strand DNA (ds-DNA) antibody (3 were positive for both). The 7 patients who exhibited renal involvement received steroid plus cyclophosphamide (CTX) treatment. Of these patients, 4 achieved various degrees of remission, 2 were at the beginning of induction therapy, and one was lost to follow-up. Two patients with isolated pulmonary involvement received steroid plus leflunomide treatment and achieved complete remission. Diffuse alveolar hemorrhage was the most frequent presentation of lung involvement in children with MPA, and tachypnea, cough, hemoptysis and anemia were the common clinical symptoms. The majority of these patients exhibited hematuria, proteinuria and renal insufficiency. The efficacy of steroid plus CTX or leflunomide was evident in these patients.
Collapse
Affiliation(s)
- Haiyan Wang
- Department of Pediatrics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong, Peoples’ Republic of China
| | - Liangzhong Sun
- Children’s Kidney Disease Center, Department of Pediatrics, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, Peoples’ Republic of China
| | - Weiping Tan
- Department of Pediatrics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong, Peoples’ Republic of China
- * E-mail:
| |
Collapse
|
6
|
Abstract
Pulmonary arteritis is a rare cause of pulmonary hypertension. Causes of pulmonary arteritis can be divided into primary and secondary, as well as classified according to vessel size. Only large vessel vasculitis is associated with pulmonary hypertension; primary forms include Takayasu arteritis and giant cell arteritis. The diagnosis of pulmonary arteritis can be challenging and the associated morbidity is serious without prompt, directed treatment. The authors present a case involving a 48-year-old First Nations man presenting with a six-month history of exertional dyspnea and severe stenosis of the left pulmonary artery, who was ultimately diagnosed with pulmonary arteritis related to large vessel vasculitis.
Collapse
Affiliation(s)
- Suzana M Gilmour
- Department of Medicine, University of British Columbia, Vancouver, British Columbia
| | - Giulio S Dominelli
- Respiratory Division, Department of Medicine, University of British Columbia, Vancouver, British Columbia
| | - Jonathon A Leipsic
- Department of Radiology, University of British Columbia, Vancouver, British Columbia
| | - Robert D Levy
- Respiratory Division, Department of Medicine, University of British Columbia, Vancouver, British Columbia
| |
Collapse
|
7
|
Martín-Suñé N, Ríos-Blanco JJ. Pulmonary affectation of vasculitis. Arch Bronconeumol 2012; 48:410-8. [PMID: 22682604 DOI: 10.1016/j.arbres.2012.04.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2012] [Accepted: 04/09/2012] [Indexed: 10/28/2022]
Abstract
Respiratory tract affectation is frequent in some types of vasculitis, fundamentally in those associated with anti-neutrophil cytoplasmic antibodies (ANCA). The clinical, radiological and histopathological presentation is also heterogeneous and conditions the evolution. It is therefore necessary to establish an early diagnosis based on the symptoms because, thanks to new treatments, and despite them being potentially serious diseases, their prognosis has improved considerably in recent years. The present paper updates the diagnosis and the new therapeutic options for pulmonary vasculitis.
Collapse
|
8
|
Watanabe E, Diniz LR, da Mota LMH, Barros SM, de Carvalho JF. Pulmonary capillaritis leading to alveolar hemorrhage in a juvenile idiopathic arthritis patient: first description. Rheumatol Int 2011; 32:1855-7. [PMID: 21833521 DOI: 10.1007/s00296-011-2035-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2011] [Accepted: 07/10/2011] [Indexed: 11/28/2022]
Abstract
Juvenile idiopathic arthritis (JIA) is characterized by the typical joint involvement and some patients have extra-articular lesions, such as uveitis and pleuritis. However, until this date, no case of alveolar hemorrhage in JIA has been described. Herein, the authors describe a case of a male patient, 33 years old diagnosed as polyarticular JIA who had a dramatic evolution with alveolar hemorrhage secondary to pulmonary capillaritis. He received intravenous immunoglobulin and pulse therapies with glucocorticoid and cyclophosphamide with a satisfactory outcome. In addition, the authors review this important pulmonary complication in rheumatic diseases.
Collapse
|